1. A. An administrator shall ensure that:

   1. 1. A medical record is established and maintained for each patient according to A.R.S. Title 12, Chapter 13, Article 7.1;

   2. 2. An entry in a patient’s medical record is:

      1. a. Recorded only by a personnel member authorized by policies and procedures to make the entry;
      2. b. Dated, legible, and authenticated; and
      3. c. Not changed to make the entry illegible;

   3. 3. An order is:

      1. a. Dated when the order is entered in the patient’s medical record and includes the time of the order;
      2. b. Authenticated by a medical practitioner or behavioral health professional according to policies and procedures; and
      3. c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional issuing the order;
   4. 4. If a rubber-stamp signature or an electronic signature is used to authenticate an order, the individual whose signature the rubber-stamp signature or electronic signature represents is accountable for the use of the rubber-stamp signature or electronic signature;

   5. 5. A patient’s medical record is available to an individual:

      1. a. Authorized according to policies and procedures to access the patient’s medical record;
      2. b. If the individual is not authorized according to policies and procedures, with the written consent of the patient or the patient’s representative; or
      3. c. As permitted by law;
   6. 6. Policies and procedures include the maximum time-frame to retrieve a patient’s medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and
   7. 7. A patient’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a health care institution maintains a patient’s medical records electronically, an administrator shall ensure that:

   1. 1. Safeguards exist to prevent unauthorized access, and
   2. 2. The date and time of an entry in a patient’s medical record is recorded by the computer’s internal clock.

3. C. An administrator shall ensure that a patient’s medical record contains:

   1. 1. Patient information that includes:

      1. a. The patient’s name;
      2. b. The patient’s address;
      3. c. The patient’s date of birth; and
      4. d. Any known allergies, including medication allergies;
   2. 2. The name of the admitting medical practitioner or behavioral health professional;
   3. 3. The date of admission and, if applicable, the date of discharge;
   4. 4. An admitting diagnosis;

   5. 5. If applicable, the name and contact information of the patient’s representative and:

      1. a. If the patient is 18 years of age or older or an emancipated minor, the document signed by the patient consenting for the patient’s representative to act on the patient’s behalf; or

      2. b. If the patient’s representative:

         1. i. Is a legal guardian, a copy of the court order establishing guardianship; or
         2. ii. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney;
   6. 6. If applicable, documented general consent and informed consent by the patient or the patient’s representative;
   7. 7. Documentation of medical history and results of a physical examination;
   8. 8. A copy of the patient’s health care directive, if applicable;
   9. 9. Orders;
   10. 10. Assessment;
   11. 11. Treatment plans;
   12. 12. Interval note;
   13. 13. Progress notes;
   14. 14. Documentation of health care institution services provided to the patient;
   15. 15. Disposition of the patient after discharge;
   16. 16. If applicable, documentation of any actions taken to control the patient’s sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;
   17. 17. Discharge plan;
   18. 18. A discharge summary, if applicable;

   19. 19. If applicable:

       1. a. Laboratory reports,
       2. b. Radiologic reports,
       3. c. Diagnostic reports, and
       4. d. Consultation reports; and

   20. 20. Documentation of a medication administered to the patient that includes:

       1. a. The date and time of administration;
       2. b. The name, strength, dosage, and route of administration;

       3. c. For a medication administered for pain, when initially administered or PRN:

          1. i. An assessment of the patient’s pain before administering the medication, and
          2. ii. The effect of the medication administered;

       4. d. For a psychotropic medication, when initially administered or PRN:

          1. i. An assessment of the patient’s behavior before administering the psychotropic medication, and
          2. ii. The effect of the psychotropic medication administered;
       5. e. The identification, signature, and professional designation of the individual administering or observing the self-administration of the medication; and
       6. f. Any adverse reaction a patient has to the medication.

Historical Note

Adopted effective July 6, 1994 (Supp. 94-3). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).